CHAPTER 3

IMPAIRMENT OF SPINE AND LIMBS

This chapter contains six parts:

Part 3.1 — Upper Limbs

Part 3.2 — Lower Limbs

Part 3.3 — Spine

Part 3.4 — Resting Joint Pain

Part 3.5 — Ranges of Joint Movement

Part 3.6 — Spine and Limbs Age Adjustment

INTRODUCTION

This chapter is used to assess the motor function of the spine and limbs. Sensory loss is to be assessed under Chapter 5 (Neurological Impairment).

Impairment of limbs

When a previously-accepted condition is later removed by an amputation that is also an accepted condition, the rating is to be based on the amputation or the resulting functional deficit, whichever results in the higher impairment rating. The previously accepted condition is not to be given an impairment rating.

Functional impairment is to be calculated separately for each upper limb. Thus one functional impairment rating may be calculated for the right upper limb and another for the left upper limb.

Follow the steps below to calculate the impairment rating for accepted conditions of each upper limb:

(Steps 2–8 are elaborated in the following pages.)

For the purposes of assessment under the Guide, the major joints of the upper limb are the shoulder, the elbow and the wrist.  

In addition, the joints of the thumb and fingers are also to be considered. However, only one rating is to be given for the total effect of restrictions in all joints of the thumb and fingers considered together.

Conditions such as painful arc syndrome and fractured neck of radius may affect the range of movement (ROM) of the shoulder. A condition such as fractured scaphoid will be likely to affect the ROM of the wrist. In cases of fractures, the ranges of movements of the joints proximal to and distal to the fracture site should generally be considered as joints the ROM of which may be affected.

Hence, it must be determined which, if any, of

• shoulder;
• elbow;
• wrist; and
• thumb and fingers,

potentially have loss of range of movement due to accepted conditions.

Certain vascular conditions or neurological conditions of the upper limb, such as muscle weakness, tremor, apraxia, and loss of co-ordination, may have an effect on the function of the upper limb without restricting the range of movement of any joint of the limb. The assessment of such conditions is to be made under Step 4 of this Part.

Single functional impairment ratings may be obtained for each of the following four joints or sets of joints based on restriction of range of movement due to accepted conditions:

• shoulder;
• elbow;
• wrist; and
• thumb and fingers.

These impairment ratings are to be obtained by applying Table 3.1.1. Such functional impairment ratings are referred to as the functional impairment rating of the upper limb based on restriction of range of movement of the shoulder, elbow, wrist, or thumb and fingers respectively.

The loss of range of movement is to be estimated to the nearest quarter of the normal range of movement.

The range of movement relevant to assessment under this Guide is the active range of movement of the joint, that is the range through which the veteran can move the joint by virtue only of those muscles whose normal function it is to do so. The ability of a veteran to flex a joint by use of other, non-affected body parts does not reduce the rating which the impaired joint attracts. (For example, if a veteran cannot flex the right elbow in the normal fashion, by use of the right biceps, but can use the left hand to bend the right elbow, the right elbow should be assessed as having “loss of almost all movement”.)

The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be related directly to items within Table 3.1.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement must be compared with the average range of movement of a normal joint to obtain the fractional loss of range of movement.

The average ranges of movement of various normal joints of the upper limb may be obtained from Table 3.5.1 in Part 3.5. These values are to be used in arriving at the fractional loss of range of movement when the actual movements of a joint are known in degrees.

If non-accepted conditions contribute to the loss of range of movement, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.1.

Ratings from this table are age adjusted (see Table 3.6.1)

Table 3.1.2 measures the loss of function relating to the upper limb as a whole. Only one rating is to be given from this table, for the right upper limb, for any condition or combination of conditions. To attract a particular rating, the degree of impairment must be greater than that described at all lower levels.

Table 3.1.2 is the only relevant table if the use of an upper limb is restricted by vascular conditions or neurological conditions, such as muscle weakness, tremor, apraxia, loss of co-ordination, fatigue or pain, and when no condition affecting the range of movement of a joint is present.

If non-accepted conditions contribute to the loss of function, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.1.2.

After the application of Chapter 19 (Partially Contributing Impairment) in Step 3, the functional impairment rating from loss of range of movement is to be compared with the functional impairment for the use of the limb as whole.

The higher of these two ratings is then taken as the final functional impairment rating for the right upper limb.

The functional impairment rating obtained in Step 4 is to be age adjusted by applying Table 3.6.1.

Total loss of function of each upper limb is considered to be 60 per cent impairment of the whole person. Amputation of an arm at the shoulder joint, or total loss of use of an arm is equivalent to 60 impairment points.

With the exception of a forequarter amputation, no condition or combination of conditions affecting an arm shall receive an impairment rating exceeding 60 points.

In the case of a veteran aged 45 years or less, if the application of age adjustment to the functional impairment rating of an accepted condition affecting the right upper limb results in an impairment rating higher than 60 impairment points, the functional impairment rating for the right upper limb is to be taken as 60 impairment points and not at the higher rating obtained by applying Table 3.6.1.

Ratings from this table are age adjusted (see Table 3.6.1)

There are three Other Impairment tables relating to the upper limb. These are:

Table 3.1.3 — Amputations of Fingers and Thumb; and

Table 3.1.4 — Amputations of Upper Limb; and

Table 3.1.5 — Dislocation of Shoulder.

Not more than one rating may be selected from either Table 3.1.3 or Table 3.1.4, if the veteran has an amputation affecting the right upper limb.

An additional rating may be selected from Table 3.1.5 if it is applicable to the right shoulder.

If no ratings from Tables 3.1.3 or 3.1.4 or 3.1.5 apply to the right upper limb, then the functional impairment rating obtained under Step 6 is the final functional impairment rating for the right upper limb.

The final functional impairment rating obtained in Step 6 is to be compared with the impairment rating for that limb obtained in Step 7 (if any).

The higher of the two ratings is then to be taken as the total final impairment rating for the right upper limb.

If multiple accepted conditions are responsible for the impairment of an upper limb, the situation will be more complicated and may require applying Chapter 20 (Apportionment).

If the veteran has received a rating from either Table 3.1.3 or Table 3.1.4 and also a rating from Table 3.1.5 the substeps below are to be followed.

No age adjustment permitted for this table

No age adjustment permitted for this table

No age adjustment permitted for this table

Example 1

A veteran has an amputation of the right thumb as the only accepted disability of the right upper limb.

By following steps 1 to 7 inclusive,  a rating will have been selected

from Table 3.1.2:

probably 20 to 40 impairment points (depending on the severity of the effect on the hand)

from Table 3.1.3:

20 impairment points.

These two ratings are compared and the veteran receives the higher as the final impairment rating for the right upper limb.

Example 2

A veteran has an amputation of his right thumb and dislocation of the right shoulder as the only accepted conditions of the right upper limb.

By following steps 1 to 7 inclusive, a rating will have been selected

from Table 3.1.2:

say, 40 impairment points (the veteran can use the right upper limb reasonably well in a few circumstances only)

from Table 3.1.3:

20 impairment points; and

from Table 3.1.5:

10 impairment points.

Medical evidence shows that the incapacity of the veteran’s right upper limb is due 80% to the shoulder condition and 20% to the amputated thumb. Apportioning the 40 impairment points in the ratio of 4:1, 34 points are obtained for the shoulder, and 9 points for the thumb (Table 20.1).

After comparing the apportioned functional impairment rating of 34 for the right shoulder with the Other Impairment rating of 10 from Table 3.1.5, the veteran gets 34 points for the shoulder. After comparing the apportioned functional impairment rating of 9 for the amputated right thumb with the Other Impairment rating of 20 from Table 3.1.3, the veteran gets 20 points for the amputation of the right thumb.

In this case the final impairment ratings for the right upper limb are 34 points and 20 points. These are to be included in the final combining of all ratings.

Because the two lower limbs constitute a functional unit, a single functional impairment rating is calculated for both lower limbs together.

Follow the steps below to calculate the impairment rating due to accepted conditions of the lower limbs:

(Each step is elaborated in the following pages.)

For the purposes of assessment under this Guide, the major joints of the lower limbs are the hip, the knee and the ankle.  

In addition, the joints of the toes are also to be considered. However, only one rating is to be given for the total effect of restrictions in all joints of the toes of one foot considered together.

Conditions such as chondromalacia patellae and torn medial meniscus may affect the range of movement of the knee. A condition such as fractured neck of femur will be likely to affect the range of movement of the hip. In cases of a fracture, the ranges of movements of the joints both proximal to and distal to the fracture site should generally be considered as joints the range of movement of which may be affected. The closer a fracture site is to a joint, the more likely it is that it will have some effect on the range of movement of that joint.

Hence, it must be determined which, if any, of both right and left:

• hip;
• knee;
• ankle; and
• toes;

potentially have loss of range of movement due to accepted conditions.

Certain vascular conditions or neurological conditions of the lower limb, such as muscle weakness, tremor, apraxia, or loss of co-ordination may have an effect on the function of the lower limb without restricting the range of movement of any joint of the limbs. The assessment of such conditions is made under Step 4 of this Part.

Single functional impairment ratings may be obtained for each of the following eight joints or sets of joints based on restriction of range of movement due to accepted conditions:

These impairment ratings are obtained by applying Table 3.2.1. Such functional impairment ratings are referred to as the functional impairment rating of the relevant lower limbs based on restriction or range of movement of the right or left hip, knee, ankle, or toes respectively.

The loss of range of movement is to be estimated to the nearest quarter of the normal range of movement.

The range of movement relevant to assessment under this Guide is the active range of movement of the joint, that is the range through which the veteran can move the joint by virtue only of those muscles whose normal function it is to do so. The ability of a veteran to flex a joint by use of other, non-affected body parts does not reduce the rating which the impaired joint attracts. (For example, if a veteran cannot flex the right knee in the normal fashion, by use of the hamstring muscles, but can use a hand to bend the right knee, the right knee should be assessed as having “loss of almost all movement”.)

“Unfavourable position” and “position of function” and “flail joint” are defined at page 41.

The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be related directly to items within Table 3.2.1. However, sometimes, the measured movements of an affected joint will be available in degrees. In such a case the measured movement is to be compared with the average range of movement of a normal joint to obtain the fractional loss of range of movement.

The average ranges of movement of various normal joints of the lower limbs may be obtained from Table 3.5.1 in Part 3.5 of this Chapter. These values are to be used in arriving at the fractional loss of range of movement when the movements of a joint are known in degrees.

If non-accepted conditions contribute to the loss of range of movement, Chapter 19 (Partially Contributing Impairment) is to be used in conjunction with Table 3.2.1.

If various impairment ratings have been obtained for lower limb joints, and Chapter 19 has been applied to them, take the highest resultant rating. This is the final functional impairment rating for the lower limbs based on loss of range of movement. If Chapter 19 did not have to be applied, then take the highest of the various impairment ratings that have been obtained for each lower limb joint. In that case, this is the final functional impairment rating for the lower limbs.

Ratings from this table are age adjusted (see Table 3.6.1)

The functional impairment rating based on loss of range of movement obtained in Step 2 is to be age adjusted using Table 3.6.1.

For veterans aged 46 to 55 years at the relevant time, age adjustment will not result in any change of the impairment rating. For veterans aged 56 years and older at the relevant time, the impairment rating will be reduced by an amount dependent upon their age. For veterans aged 45 years or less at the relevant time, the impairment rating will be increased by an amount dependent upon their age.

Total loss of function of each lower limb is considered to be 50 per cent impairment of the whole person. Amputation of a lower limb at the hip joint, or total loss of the use of a lower limb is equivalent to 50 impairment points.

With the exception of a hindquarter amputation, no condition or combination of conditions causing impairment in a lower limb shall receive an impairment rating exceeding 50 points.

In the case of a veteran aged 45 years or less, if the application of age adjustment to the functional impairment rating results in an impairment rating higher than 50 impairment points, the functional impairment rating for that lower limb is to be taken as 50 impairment points and not as the higher rating obtained by applying Table 3.6.1.

Table 3.2.2 measures the loss of function relating to the two lower limbs together. Only one rating is to be given from this table for any condition or combination of conditions. To attract a particular rating, the degree of impairment must be greater than that described at all lower levels.

Impairment ratings derived from Table 3.2.2 are not to be age adjusted by applying Table 3.6.1. The reason is that many of the criteria within the table are age-dependent: they compare veterans with others of the same age.

Table 3.2.2 is the only relevant table if the use of lower limbs is restricted by vascular conditions or neurological conditions, such as muscle weakness, tremor, apraxia, loss of co-ordination, fatigue or pain, and when no condition affecting the range of movement of a joint is present.

If non-accepted conditions contribute to the loss of function, Chapter 19 (Partially Contributing Impairment) is to be applied in conjunction with Table 3.2.2.

No age adjustment permitted for this table

For the purposes of Table 3.2.2 “transfer” means:

• a move from one seat to another;
• a move from sitting to standing;
• a move on and off the toilet; or
• a move in and out of bed.

After applying Chapter 19 (Partially Contributing Impairment) in Step 4, the functional impairment rating from loss of range of movement is to be compared with the functional impairment for the use of the limbs as whole.

The higher of these two ratings is the final functional impairment rating for the limbs.

There are two Other Impairment tables relating to the lower limbs:

Table 3.2.3 — Amputations of Lower Limbs; and

Table 3.2.4 — Lower Limbs - Joint Replacements.

No age adjustment permitted for this table

No age adjustment permitted for this table

Example:

A veteran has an amputation of his right foot as the only accepted condition of his lower limbs which upon investigation is found to fit the description of “amputation below knee with functional stump”.

By following steps 1 to 6 inclusive, a rating will have been selected:

from Table 3.2.2:

probably 10 to 30 impairment points (depending on the severity of the effect of the amputation on the particular veteran);

from Table 3.2.3:

30 impairment points.

These two ratings are to be compared and the veteran receives the higher as the total final impairment rating for his amputation of right foot.

If multiple accepted conditions are responsible for the impairment of the lower limbs, the situation will be more complicated and may require applying Chapter 20 (Apportionment).

In some cases, two other impairment ratings are to be given. In such cases, the functional impairment for the limbs should be apportioned into three parts:

• one part corresponding to the impairment due to any amputation of the right leg;
• one part corresponding to the impairment due to any amputation of the left leg; and
• one part corresponding to all other causes.

Example:

A veteran has osteoarthritis of both knees as an accepted condition and has had bilateral knee replacements resulting in reasonably good function. The veteran also has peripheral vascular disease as an accepted condition which limits walking distance to about 200 metres.

By following steps 1 to 6 inclusive,  a rating will have been selected:

from Table 3.2.2:

20 impairment points; and

two ratings will have been selected from Table 3.2.4:

10 impairment points for the right knee replacement; and

10 impairment points  for the left knee replacement.

The veteran receives all three impairment ratings. The three ratings are to be included in the final combining of all impairment ratings.

The following conditions, whether alone or in combination, are to be assessed by applying Table 3.2.5 if they have no effect on lower limb function. If these conditions have an effect on lower limb function they are to be assessed by applying Table 3.2.2.

No age adjustment permitted for this table

A Lower Limbs Worksheet is provided on page 69.

A single Lower Limbs Worksheet is to be used for both lower limbs together. The Lower Limbs Worksheet is designed to facilitate calculation of the functional impairment of the lower limbs. That functional impairment is to be compared with any Other Impairment ratings in accordance with this Guide.

Part 3.3 of Chapter 3 is to be applied in assessing impairment of the spinal column, not of the spinal cord. Impairments of the spinal cord are to be assessed by applying Chapter 5 of this Guide.

For the purposes of assessment under Part 3.3 the spine consists of two parts — the cervical spine and the thoraco-lumbar spine — each of which is to be given a separate impairment rating if appropriate.

Follow the steps below to determine the impairment rating from accepted conditions affecting the function of the spine. Because the cervical spine and the thoraco-lumbar spine are each to be separately assessed, this set of steps is to be followed twice (if applicable): once for the cervical spine and once for the thoraco-lumbar spine.

(Each step is elaborated in the following pages.)

Table 3.3.1 is to be applied to rate spinal function. It is based on range of movement of the spine. Two ratings may be given from this table — one for the cervical spine and one for the thoraco-lumbar spine. Only one rating is to be given for the cervical spine for any condition or combination of conditions which contribute to the loss of range of movement of the cervical spine. Only one rating is to be given for the thoraco-lumbar spine for any condition or combination of conditions that contribute to the loss of range of movement of the thoraco-lumbar spine.

It is not practicable to measure range of movement of the thoracic spine independently of that of the lumbar spine. If only the thoracic spine is to be rated, all movements are to be measured, but emphasis is given to rotation. If only the lumbar spine is to be rated, all movements are to be measured, but emphasis is given to forward flexion. However, even if conditions of both the thoracic and lumbar spine are to be assessed, only one rating is to be made from the thoraco-lumbar spine column of Table 3.3.1.

The loss of range of movement should be estimated to the nearest quarter of the normal range of movement.

The loss of range of movement will usually be provided as a fractional loss of range of movement and such data can be used directly in Table 3.3.1. However, sometimes, the measured movements of the affected part of the spine will be available in degrees. In such a case the measured movement is to be compared with the average range of movement of the normal spine to obtain the fractional loss of range of movement.

The average ranges of movement of the normal spine may be obtained from Table 3.5.1 in Part 3.5. These values are to be used in arriving at the fractional loss of range of movement when the actual movements of the spine are known in degrees.

If a functional impairment rating obtained from Table 3.3.1 has been contributed to by any non-accepted conditions, then that rating is to be moderated by applying Chapter 19 (Partially Contributing Impairment).

Table 3.3.2 is to be applied to assess functional loss of the thoraco-lumbar spine that is not adequately measured by loss of range of movement.  Ratings obtained from Table 3.3.2 are not to be combined with any ratings obtained from Table 3.3.1 in respect of the thoraco-lumbar spine. Ratings obtained from Table 3.3.2 are compared with ratings obtained from Table 3.3.1 in respect of the thoraco-lumbar spine in Step 3.

If a functional impairment rating obtained from Table 3.3.2 has been contributed to by any non-accepted conditions, then that rating is to be moderated by applying Chapter 19 (Partially Contributing Impairment).

Ratings from this table are age adjusted (see Table 3.6.1)

Ratings from this table are age adjusted (see Table 3.6.1)

The functional impairment rating obtained in Step 4 is to be age adjusted by applying Table 3.6.1. Unlike the situation which applies to the upper and lower limbs there is no maximum value of the impairment rating of the spine. Hence whatever the rating obtained by application of Table 3.6.1 is the rating to be given. (The reason is that the maximum rating for limbs is determined by reference to the rating given for amputation of the limb, but there is no such thing as amputation of the spine.)

The Other Impairment ratings of the spine are those due to crush fractures of the vertebrae.

No age adjustment permitted for this table

After applying Chapter 19 (Partially Contributing Impairment), the functional impairment rating due to loss of range of movement of the spine is to be compared with the functional impairment due to any crush fractures.

The higher of these two ratings is the final functional impairment rating for the cervical or thoraco-lumbar spine, as the case may be.

The assessment of other effects of spinal conditions.

If a spinal condition causes an effect on limb function, then that effect on limb function is also to be assessed under Parts 3.1 or 3.2 of this chapter (together with the effect of any other accepted conditions contributing to loss of function of the same limb); and if a spinal condition causes a sensory loss, then that sensory loss is also to be assessed under Table 5.4 (together with the effect of any other accepted conditions contributing to that sensory loss).

For example, if a spinal condition which causes a reduced range of spinal movement also interferes with the proper function of the limbs, then a rating from Table 3.3.1 may be combined with a rating from Table 3.1.2 or 3.2.2.

A Cervical Spine Worksheet is provided at page 71.

A Thoraco-Lumbar Spine Worksheet is provided at page 72.

An additional rating is to be given from Table 3.4.1 for certain joint pain. This table is to be applied only for frequent joint pain that continues to affect a joint when the joint is no longer in use: for example, pain in the knees continuing for a significant period after ceasing walking and standing, or pain in the shoulders persisting for a significant period after ceasing some task such as hanging out the washing. Pain that limits range of movement or distance that can be walked is already assessed elsewhere (Tables 3.2.1 and 3.2.2).

Table 3.4.1 may be applied for pain in both the upper limbs and lower limbs and intervertebral joints. Only one selection may be made from this table for pain in any joint or combination of joints. However, the table is not to be applied to rate sciatic pain. Sciatic pain is to be rated  by applying Table 3.2.2.

No age adjustment permitted for this table

Table 3.5.1 is a table of “average” or “normal” values. It is to be used to assist in the estimation of loss of range of joint movement. Range of movement is usually measured by simple visual assessment, and is based on active joint movement. Because estimates of range of movement are required only to the nearest quarter of normal full range of movement, the use of a goniometer is not essential.

A global assessment is based on the measurement and averaging of movements in all planes. Functionally more important planes of movement (Table 3.5.1) are given more emphasis in this assessment. The total loss of range of movement should be estimated to the nearest quarter of the normal range of movement.

Estimates of range of movement may be made using the joint on the opposite side for comparison, provided that the opposite side is not affected by injury or disease. If both sides are affected the accepted normal range of movement given in Table 3.5.1 can be used as a reference.

The angles in brackets represent the position of function. This information is required when considering whether an ankylosis is in a favourable position or not.

No age adjustment permitted for this table

Table 3.6.1 converts the impairment rating for the measured loss of musculoskeletal function to an age adjusted impairment rating.

This is a table for making age adjustment

Table 3.6.1 is to be applied only to impairment ratings derived from Tables 3.1.1, 3.1.2, 3.2.1, 3.3.1, and 3.3.2.

Table 3.6.1 is not to be applied to impairment ratings derived from Tables 3.1.3, 3.1.4, 3.2.2, 3.2.3, 3.2.4, 3.3.3, or 3.4.1.